Ambulatory Quality Improvement Despite COVID-19: Blueprint for a Successful System for Continuous Improvement.

ABSTRACT: In this article, we describe our experience developing and implementing a multipronged approach to improve performance across a strategic subset of quality measures within primary care. Detailed techniques include data visualization and analytics, process reengineering, team engagement, visual project management, continuous improvement methods and training, and incentives and recognition. We achieved positive change across 12 high priority measures which we deemed the "High Value Framework (HVF)" by fostering a collaborative, nonpunitive, problem-solving culture. We focused on measures that had the greatest potential for impact from a clinical, reimbursement, and reputational perspective. More importantly, we sustained gains despite the challenges posed by the COVID-19 pandemic, thereby demonstrating programmatic resilience and high process reliability. This systematic approach serves as a practical blueprint for other healthcare entities seeking to navigate the complexities of quality improvement in a dynamic environment. The model provides a strategic framework for prioritizing and standardizing quality measures, effectively engaging stakeholders, and managing organizational change. Our model emerged from a need to address real-world operational challenges, rather than as an academic or theoretical exercise, and was developed independently of existing literature on measure prioritization and standardization at the time of its inception.

Establishing Standardized Documentation for Anaphylaxis Treatment in a Tertiary Care Pediatric Allergy Clinic.

INTRODUCTION: Anaphylaxis is a potentially life-threatening allergic reaction. Common allergy clinic procedures, including oral food challenges and subcutaneous immunotherapy, carry a risk of anaphylaxis, the treatment for which is epinephrine. Our goal was to develop a standardized process for the management and documentation of allergic reactions that occur in a tertiary care pediatric allergy clinic. METHODS: This was a single institution quality improvement pilot study. A multidisciplinary team from the allergy department designed, implemented, and studied the use of a standardized form for the documentation and treatment of allergic reactions within the clinic. RESULTS: A standardized form was developed based on evidence-based guidelines for the management of allergic reactions and included space for documentation. Both clinic providers and staff approved the form. One year after the introduction, we reached 100% adherence for the use of the form in visits during which a patient experienced a severe allergic reaction requiring epinephrine. Two patients required transfer to the emergency room; the quality improvement form was utilized in these cases to document treatment and assist with the hand-off to emergency room personnel before transfer. CONCLUSIONS: We successfully implemented a standardized form for the treatment and documentation of anaphylaxis within our allergy clinic. The next steps focus on further integrating this form into the electronic medical record, determining compliance with evidence-based management of anaphylaxis, and formally assessing the use of the form as a handoff tool in the event of patient transfer.

Plant Density and Rhizosphere Chemistry: Does Marigold Root Exudate Composition Respond to Intra- and Interspecific Competition?

The development of techniques to non-destructively monitor allelochemical dynamics in soil using polydimethylsiloxane (PDMS) microtubing (silicone tubing microextraction, or STME) provides a means to test important ecological hypotheses regarding the roles of these compounds in plant-plant interactions. The objective of this study was to investigate the impact of intra- and interspecific competition on the exudation of thiophenes by marigolds (Tagetes patula L.). Marigolds were grown at a density of 1, 3 and 5 plants in pots (8.75 × 8.75 cm) containing two STME samplers. An additional treatment included one marigold surrounded by four velvetleaf (Abutilon theophrasti L.) plants. Marigold roots released two primary thiophenes, 3-buten-1-ynyl)-2,2'-bithienyl and α-terthienyl, which are readily absorbed by silicone microtubing. Thiophene exudation was monitored over the period 15-36 days after planting, at 2-5 day intervals. At the end of the study, root and soil samples were also analyzed for thiophene content. Thiophene production per plant increased over time, and thiophene release was strongly correlated with plant size. These results indicate that thiophene release in this study was passively controlled by resource availability. However, poor growth of velvetleaf plants competing with marigold suggests that thiophenes negatively influenced velvetleaf growth. This study, then, provides indirect evidence that thiophene exudation is insensitive to neighbor identity but differentially effective in inhibiting the growth of heterospecific neighbors.

Quality Improvement-Driven Reduction in Countywide Medicaid Acute Asthma Health Care Utilization.

OBJECTIVE: This study evaluates the impact of a coordinated effort by an urban pediatric hospital and its associated accountable care organization to reduce asthma-related emergency department (ED) and inpatient utilization by a large, countywide Medicaid patient population. METHODS: Multiple evidence-based interventions targeting general pediatric asthma care and high health care utilizers were implemented using standardized quality improvement methodologies. Annual asthma ED and inpatient utilization rates by 2- to 18-year-old members of an accountable care organization living in the surrounding county (>140,000 eligible members in 2016), adjusted per 1000 children from 2008 through 2016, were analyzed using Poisson regression. We compared these ED utilization rates to national rates from 2006 to 2014. RESULTS: Asthma ED utilization fell from 18.1 to 12.9 visits/1000 children from 2008 to 2016, representing a 28.7% reduction, with an average annual decrease of 3.9% (P < .001), during a time when national utilization was increasing. Asthma inpatient utilization did not change significantly during the study period. CONCLUSIONS: Asthma-related ED utilization was significantly reduced in a large population of primarily urban, minority, Medicaid-insured children by implementing a multimodal asthma quality improvement program. With adequate support, a similar approach could be successful in other communities.

Emergency Department Asthma Medication Delivery Program: An Initiative to Provide Discharge Prescriptions and Education.

BACKGROUND: Prescription fill rates for children being discharged from the emergency department (ED) after asthma exacerbations are low, placing the child at risk for additional ED visits or admissions for asthma. This article describes the implementation of an ED asthma prescription delivery service designed to improve pharmacy prescription capture and decrease ED revisit rates. METHODS: A core group developed a service to provide asthma prescriptions and education to patients in their ED room before discharge. The project assessed the percent of ED asthma patients who filled ED asthma prescriptions at the hospital outpatient pharmacy, 7-, 14-, and 30-day ED revisit rates, and patient satisfaction. INTERVENTION: Patients/families who chose to participate in the service received asthma prescriptions and education at the ED bedside. Within 1-3 days, ED outreach nurses obtained patient satisfaction survey responses via telephone. RESULTS: There was a statistically significant increase in the number of patients who filled ED asthma prescriptions at the hospital outpatient pharmacy (22.2% versus 33.8%; P < 0.0001). The decrease in 7-, 14-, or 30-day ED revisit rates for patients who received the medication delivery service compared with standard of care was not statistically significant. Patients were satisfied to very satisfied with the service. CONCLUSION: Postimplementation of a medication delivery program within the ED, there was an increase in the percentage of patients who filled ED asthma medication prescriptions at the hospital outpatient pharmacy. There was no difference in ED revisit rates for patients who enrolled in the prescription delivery service versus standard of care.

Nutrition assessment, care, and considerations of ventricular assist device patients.

A ventricular assist device (VAD) is an implantable mechanical device that is used to partially or completely replace the circulatory function of a failing heart. VADs may serve as a bridge to heart transplantation or as permanent circulatory assistance, also referred to as destination therapy. There is a paucity of information regarding the nutrition complications in VAD patients, and as such, little is presently known of the optimal means of nutrition assessment and management of these complex and often critically ill patients. In this review, a general overview of the VAD, comparisons of nutrition assessment measures, and strategies to meet the nutrition needs of these patients are provided using evidence-based information wherever possible. Because there is a lack of nutrition studies and assessment guidelines specifically for VAD patients, many of the guidelines for care of these patients are currently based on the information available for the care of patients with heart failure. Although the optimal measure to assess nutrition status remains poorly studied, a systematic, thorough nutrition assessment of patients with heart failure and heart transplant candidates prior to VAD placement appears to be important to identify those at nutrition risk and, with appropriate nutrition therapy, decrease their risk for morbidity and mortality. VAD patients with inadequate oral intake may require nutrition support to meet their nutrition needs; however, feeding the hemodynamically compromised patient provides additional challenges.